Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0692, written 17 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2024 |
|---|---|
| Reference | 2024-0692 |
| Deceased | Mary Whitlock |
| Coroner | Sonia Hayes |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mid and South Essex NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of Mid & South Essex NHS Trust 1 2 3 4 CORONER I am Sonia Hayes, Area Coroner, for the coroner area of Essex CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 1 September 2023 I commenced an investigation into the death of MARY MARGARET WHITLOCK, AGE 84. The investigation concluded at the end of the inquest on 17 December 2024. The conclusion of the inquest was Ia Aspiration of food contents Ib Fracture of Cervical Vertebra and Dementia Accident contributed to by neglect CIRCUMSTANCES OF THE DEATH Mary Whitlock died at Broomfield Hospital on 23 August 2023. Mrs Whitlock sustained a fracture of her cervical vertebra when she tripped at her care home and struck her head against the wall on 21 August 2023. Mrs Whitlock was conveyed to hospital with neck pain. CT scan of her head revealed no bleed or infarct and Mrs Whitlock returned home that night; no imaging was completed of the neck. Mrs Whitlock was in pain and could not swallow paracetamol the next morning and was readmitted to Broomfield Hospital where further scans revealed cervical fractures at C1 and C2. Advice was that she was not suitable for surgical intervention and was for conservative treatment with a collar that was difficult to tolerate. Broomfield Hospital did not provide the collar clinically recommended until 23 August 2023. Swallowing problems were a known risk for Mrs Whitlock’s injury and there was no plan for managing oral intake. Concerns about swallowing tablets and oral administration of analgesia were noted in the medical records overnight and not handed over to the day shift or reviewed in the ward round. Mrs Whitlock suffered aspiration following assisted feeding of 1 her lunch on 23 August that was treated with suctioning and oxygen with improvement in her condition. Mrs Whitlock was required to be nil by mouth, undergo chest x-ray, a Speech and Language Team assessment, antibiotics and intravenous fluids. This information was not shared with all the ward staff due to staff shortages. Mrs Whitlock was fed some of her remaining lunch and suffered shortness of breath and oxygen desaturation that required a emergency medical call at approximately 13:00 hours and Mary was place on end-of-life care and died. Mrs Whitlock sustained a Fractured Cervical Vertebrae with Dementia that put her at risk of aspiration. and she was fed when experiencing swallowing difficulties. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Morphine in the form of 5mg Oramorph and then 2.5mg Intravenous morphine was administered for a patient where the medication record noted allergy to Tramadol, Codeine and Buprenorphine. Naloxone was required to reverse the effect. Whilst this die not cause or contribute to this death this matter was not part of the Trust review, and no safeguarding was raised. (2) Evidence of clinical witnesses is that Notley Ward was (at the time of this death) and remains understaffed despite escalation within Trust (3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury 6 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 February 2025. I, the coroner, may extend the period. 2 Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family Essex County Council I have also sent it to Care Quality Commission who may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 8 9 17 December 2024 HM Area Coroner for Essex Sonia Hayes 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
H.M Area Coroner Ms Sonia Hayes SEAX House Victoria Road South Chelmsford Essex CM1 1QH Our Ref: 10 February 2025 Dear Ms Hayes Regulation 28 Report to Prevent Future Deaths – Mary Margaret Whitlock I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 17th December 2024, relating to the Inquest touching on the death of Mrs Whitlock. We have considered your concerns and set out our formal response to each matter using your numbering as follows. Matters of Concern 1) Morphine in the form of 5mg Oramorph and then 2.5mg Intravenous morphine was administered for a patient where the medication record noted allergy to Tramadol, Codeine and Buprenorphine. Naloxone was required to reverse the effect. Whilst this did not cause or contribute to this death this matter was not part of the Trust review, and no safeguarding was raised. I am advised by Emergency Department colleagues that a small dose of opiate was given to treat Mrs Whitlock’s pain, which was the likely source of her agitation. Mrs Whitlock had already received IV paracetamol therefore the options for effective analgesia were unfortunately very limited. The options were liquid ibuprofen, IV Ketorolac (available in theatres only) or Diclofenac. However, these options would have taken time to arrange, administer and take effect in a patient that was agitated, distressed, and not complying with immobilisation therefore increasing the risk of further injury. Clinical decision making at the time indicated the selection of IV opiate to deliver the faster onset of analgesia and it’s sedative properties, to gain rapid control of the situation in a more timely manner. It was a calculated risk and the possible need for naloxone was anticipated, with staff being briefed to watch for hypoventilation and hypoxia. It was apparent that the patient was sensitive to the drugs listed as allergies because they either caused sedation or hallucinations. In retrospect, the clinicians consider that a smaller dose than 2.5mg, of 1mg increments of opiate would have been more appropriate given her noted allergies. Learning from this case has been shared with Emergency Department colleagues accordingly for future practise. The choice of analgesia was not included as a term of reference for our review as it was within an acceptable range of clinical decision making, and a safeguarding was not triggered or indicated for this event. The use of opioid analgesia was made on a balance of risk basis and the risks of allergy were carefully managed. In Mrs Whitlock’s case, the correct action was taken as soon as a reaction to the opiate was identified and there was no causative effect for her care. 2) Evidence of clinical witnesses is that Notley Ward was (at the time of this death) and remains understaffed despite escalation within Trust. Our Deputy Director of Nursing for Broomfield Hospital has reviewed the staffing position on Notley Ward and confirmed that we have recruited to all vacant Registered Nurse posts, and the ward is at full establishment with no current nursing vacancies. To ensure that safe staffing levels are maintained across all wards, we have implemented a daily staffing huddle which takes place at 08:15AM Monday-Friday. The huddle review the staffing position across the site and senior colleagues make immediate redeployment/mitigation plans as required. At the weekend, we have a daily duty Matron on site to complete the same function. We have a duty Matron on site weekdays until 20:00PM to manage any staffing concerns and we have embedded clear escalation processes to the Director and Deputy Director of Nursing who can approve requests to increase staffing by sourcing bank staff/ agency support. Funded Staff Rota (FSR) reviews are completed on every inpatient ward and our nursing establishments are altered to meet nursing acuity and safe nurse to patient ratios. The FSR’s are signed-off at Director of Nursing level. 3) No Discharge Summary or Safety Netting advice was provided by the Trust to the care home for a patient with dementia who was discharged from Accident & Emergency at night where she had undergone investigations for traumatic head injury. It is of course a fundamental requirement that discharge summaries are completed for all patients and I am disappointed to note that we did not meet our expected standard on this occasion. Following Mrs Whitlock’s experience, all our Emergency Medicine clinicians have been reminded of the requirement to complete a discharge summary to all patients in every case. We have highlighted the importance of these being available to patients who are not being discharged to their own home. Nursing colleagues have also been reminded to check that this has been completed prior to the patient leaving the department upon discharge. We have included the learning from Mrs Whitlock’s case within our all-staff patient safety bulletin for January 2025 emphasising the importance of a full and accurate discharge summary being completed at the point of discharge. We plan to monitor our performance with issuing discharge summaries within our 2025 trust-wide corporate audit programme to assure ourselves with compliance and use the results to take action as appropriate. If I can assist further with these matters, please do not hesitate to contact me. Yours sincerely Chief Executive Mid and South Essex NHS Foundation Trust
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